Records and reports

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1. Presented by: Kalyani R. Saudagar R ecords and reports

2. Records Definition : Records the memory of the internal and external transactions of an organization. Records contain a written evidence of the activities of an organization in the form of letters, circular, reports, contracts, invoices, vouchers, minutes of meetings, books of account etc. (S.L.Geol,2001) It is a written communication that permanently documents information relevant to a clients health care management. It is a continuing account of the clients health care needs. ( Sr. Mary lucita )

3. Importance of Records For the individual and family: Serve the history of client Assist in continuity of care Evidence to support if legal issues arise Assess health needs, research and teaching For the doctor: Serve the guide for diagnosis, treatment, follow up and evaluation Indicate progress and continuity of care Self evaluation of medical practice Protect doctor in legal issues Used for teaching and research For the nurses: Document nursing service rendered Shows progress Guide for professional growth Indicate plan for future Judge the quality and quantity of work done Planning and evaluation of service for future improvement Communication tool between nurse and other staff involved in the care

4. For authorities : Statistical information Administrative control Future reference Evaluation of care in terms of quality, quantity and adequacy Help supervisor to evaluate service Guide staff and students Legal evidence of service render by each employee Provide justification of expenditure of funds

5. PRINCIPLES OF MAINTAINING RECORDS : Specific purpose which should be clearly understood Items on forms and in registers should be conveniently grouped so as to make their completion as easy as possible The wording should be easily understood and where doubt is likely to arise ,instructions to facilitate interpretation should be included Records should permit some freedom of expression Records which are required by the teaching staff should be easily accessible to them Person responsible for maintaining records should be aware of their particular responsibility and every effort should be made to keep records up to date and accurate Provision for periodic review of all records to ensure that they keep pace with the changing needs of the program Adequate, safe, fireproof, storage arrangements

6. CLASSIFICATION OF RECORDS Active Record – a record that is regularly referenced or required for current use Inactive Record – a record that is still needed by an organization but not for current operations Electronic Record – a record recorded or formatted only a computer can process

7. CHARACTERISTIC OF GOOD RECORDING AND REPORTING ACCURACY CONSCIOUSNESS THOROUGHNESS UP TO DATE ORGANIZATION CONFIDENCIALITY OBJECTIVITY

8. PURPOSE OF KEEPING RECORDS : Communication Aids to diagnosis Education documentation of continuity Research Legal documentation Individual case study

9. RECORDS IN THE NURSING OFFICE AND UNIT Administrative records: Organogram , job description, procedure manual Personnel records: personal files, records Patient related records: patients records send to medical director Leave record, duty record, meeting minutes, budget etc Miscellaneous: circular ,round book, formats etc

10. Administrative purpose of clinical records Legal documents: poisoning, assault, rape, LAMA, burn etc Research or statistics: rates Audit and nursing audit Quality of care Continuity of care Informative purposes: man and female census Teaching purpose of students Diagnostic purposes: test reports

11. Uses of records Show the health conditions as it is and as the patient and family accepts it Goals towards which means are to be directed Prevents duplication of services and helps follow up services effectively Helps the nurse to evaluate the care and the teaching Organization of work Serves as guide for diagnosis treatment and evaluation of services Indicate progress Used in research The health assets and needs of the village area

12. TYPES OF RECORDS

13. Patients clinical records it is the knowledge of events in the patient illness, progress in his or her recovery and the type o f care given by the hospital personnel Scientific and legal Evidence to the patient the his/her case is intelligently managed Avoids duplication of work Information for medical and legal nursing research Aids in the promotion of health and care Legal protection to the hospital doctor and the nurse

14. Individual staff records A separate set of record is needed for staff, giving details of their sickness and absences, their carrier and development activities and a personnel note Ward record Reducting or increase in beds Change in medical staff and non nursing personnel for the ward The introduction and pattern of support

15. Administrative records with educational value Treatments Admission Equipments losses and replacements Personnel performance Other administrative records

16. Types of records in the department of public health Cumulative or continuing records Family records Registers reports

17. Filling and arranging of records Alphabetically Numerically Geographically With index cards Alphabetically Dictionary order Encyclopedic order

18. Advantages and disadvantages of alphabetically arrangement system

19. With index cards An index card consists of heavy paper cut to a standard size, used for recording and storing small amounts of discrete data. It was invented by Carl Linnaeus, around 1760 Eg :- forms, case records and registers Diaries-diary of M & F Return-monthly report of HW(M&F) In addition each organization should maintain cumulative records family records

20. Record keeping system Source records Problem oriented Nursing cardex Computerised information system

21. Guidelines for documentation and record keeping The nursing and midwifery council(NMC 2002) has said that patient and client records should: Be based on fact, correct and consistent Be written as son as possible after an event has happened Be written clearly and in such a way that the text cannot be erased Be written in such a way that any alteration or additions are dated, timed and signed, so that the original entry is still clear Be accurately dated, timed and signed, with the signature, irrelevant speculation and offensive subjective statements Be readable on any photocopies

22. Importance of records in hospital or health centers Individual and Family For the Doctors For the Nurse For Authorities

23. Nurses responsibility for record keeping Keep under safe custody of nurses No individual sheet should be separated Not accessible to patients and visitors Strangers is not permitted to read records Records are not handed over to the legal advisors without written permission of the administrative Handed carefully. Not destroyed Identified with bio-date of the patients such as name, age, admission number, diagnosis, etc.(legal issues?) Never sent outside of the hospital without the written administrative permission

24. PRECAUTIONS: Kept carefully Protected against termites and insects Good filling system Easily available on time Kept at definite place confidential

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